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Autism Parenting Secrets
Earlier Detection Creates More Options
00:39:26
Dr. Judy Van de Water and Dr. Michael Paul from MARAbio share a fascinating area of autism research focused on the maternal immune system and earlier biological detection. Their work is opening new possibilities for families by helping identify a specific immune-system-mediated subtype of autism before symptoms emerge. The secret this week is… Earlier Detection Creates More Options
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- [00:00]
A
We're talking about potentially the largest single known contributor to an autism diagnosis. And if you think about this, being able to inform a parent even prior to conception, that allows family planning discussions to happen. That is really not available with respect to, say, genetic testing.
- [00:20]
B
If you're a parent of a child with autism, you are being called to rise with love, courage and clarity. This journey isn't easy and most parents aren't equipped, but you can be. This podcast is your invitation to rise higher because how you navigate matters. I'm Len, and this is Autism Parenting Secrets, where you become the parent your child needs now. Hello and welcome to Autism Parenting Secrets. Most parents are told autism can only be identified after behavioral symptoms appear. But what if important biological clues exist much earlier? And what if understanding those clues sooner could help parents make more informed decisions and access support earlier? My guests today are Dr. Judy Vandewater and Dr. Michael Paul from Mara Bio. And Dr. Vandewater is a world renowned immunologist at UC Davis whose research helped identify maternal autoantibody related autism, or Mara. It's an immune system mediated subtype of autism. And Dr. Michael Paul is the CEO of Mara Bio and he's spent decades helping advance autism related diagnostics and emerging technologies, all designed to improve outcomes for children and families. Together, they're advancing a new conversation around earlier biological detection and what it could mean for families. The secret this week is earlier detection creates more options. Welcome to you both.
- [01:54]
C
Thank you so much.
- [01:56]
A
Thanks, Lyn. Great to be here.
- [01:57]
B
Well, I'm excited for the conversation And I think, Dr. Judy, let's start with you. If you could take us back to the beginning. What first led you to explore that connection between the maternal immune system and autism?
- [02:10]
C
Well, yeah, that has been a long journey. The really the beginning started because I've been working in autoimmune disorders my entire career and we were exploring what could be happening during the pregnancy period that might impact outcome, developmental outcome of the child. And historically we know from disorders like systemic lupus that when maternal autoantibodies or antibodies to self proteins go across the placenta into the fetal compartment, they can impact how the child develops. And in the case of lupus, you get congenital heart block. So that really is how we started. And it began with just very basic exploratory, is there, there, there type of science. And we got lucky and found that when we were testing for autoantibodies in a population of women who had an autistic child that they would come up positive where the control samples did not. And from There, we refined it, we identified what the proteins were that these antibodies are recognizing. And that is where we turned that into something that we hope is useful back to the community.
- [03:30]
B
Wonderful. Yeah, no, that makes sense. I guess I teed it up at the beginning in terms of what Mara stands for, this maternal auto antibody related autism. So for someone who's listening, can you unpack that a little bit? If that is a path or a type, what makes a difference from other pathways that might be relevant? So what is it about Mara that you can help the listener understand a little bit more deeply?
- [03:57]
C
I think this is a very different mechanism than we typically think of in terms of autism risk. This is something that is produced by a woman who, not necessarily during pregnancy, but during pregnancy autoantibodies, which are antibodies, as I said, that react to self proteins. There's nothing you can do about these in terms of, there's nothing you did that generated them. There's something that happens to millions of people with autoimmune disorders. But in this case, these antibodies happen to recognize proteins that are present in the developing brain. And unfortunately, along with all the healthy antibodies that cross the placenta to protect that fetus from everything that you've been exposed to, these antibodies are also present and they can find their target and in doing so can change the way the brain develops. And you know, we've done a lot of work showing that these antibodies actively do change the way brain develops using our animal models. So what maternal autoantibody related autism stands for is this very specific route to autism. These antibodies are highly specific for autism and we very rarely see them in a population of neurotypical development. And thus for us, that became really sort of a pivot point of okay, if this is happening, why is it happening, how is it happening? And potentially what can we do about it?
- [05:30]
A
Got it.
- [05:30]
B
And if you had to ballpark it, what percent of what's diagnosed as autism? And I know that's a crazy wide spectrum and probably an impossible question, but I think you touched on that this might be somewhat large, less common. Is it like a 10%, perhaps that might be related to this, or is it something smaller?
- [05:49]
C
I have a research program and we have the bio commercial program, but in the research realm it really ranged from 10 to 12% up to 26%, depending on the population that we were looking at. And that higher percent was in the population of women who were at high risk because they'd already had a child with autism. And we were testing them during a second pregnancy. But the percentage Also ranged depending on the population we're looking at regionally. So it does vary a little bit depending on where the samples, where, you know, where the person resides, where the samples came from. But a lot more work is needed to get, you know, a bigger picture of, you know, different populations across the US and internationally.
- [06:36]
A
And lan, if I could jump in a little bit, Judy's humility about this discovery is humbling in and of itself. I mean, this is her, what I say, her life's work. This has been over 20 years of research. To be able to summarize it in a few sentences is pretty remarkable. And I think from a background perspective, I've been an admirer of Judy's work. And having come from, I'll share a little bit from the autism genetic testing side. And I've been in this space for about 20 or 25 years, so I think between Judy and myself, we've been in this space for about 50 years combined, probably. But your question about kind of what it is and how it differs and in the percentage, I think is a really good question because I think it's really important to describe what this is not. This is not genetic in origin. And when we think about autism, when we think about the heritability of autism, we think of this high heritability estimate, which from twin studies and from other published research can be as high as 60%, 70%, but yet we have not yet discovered, if you will, all of the genetic variants that could account for that heritability. And there's something called missing heritability. So what's missing in that heritability and what attracted me for a couple things, what One was these antibodies that are being inherited from the mom, and Judy's right, nothing that they did wrong. We've actually now identified that men carry these antibodies too, so this is in women and men, but that these antibodies are inherited, so to speak, from the mom's circulation and so are contributing to that estimate of heritability. But because it's not transferred from the mother or the father's DNA, so called their germline, there's actually unique opportunities to intervene with the Mara subtype that you're not able to intervene from a more genetic subtype. If you could somehow block, prevent, ameliorate the pathogenic effect of these antibodies on the developing fetus, you could go a long ways to diminishing, if you will, or lessening the impact on the potential child. So there's really some unique aspects here and as you mentioned in the beginning, provides parents with More options if they know that this is a likely subtype of their child's autism.
- [09:13]
B
Right. And the idea of knowing that, knowing that piece of information could be critically important because just like with functional genomics and your genes, right. There's no cause of any. There's no gene that causes autism or anything else. But if you do know what the DEC is that you have, what your blueprint is, that information can help inform actions you can take now that might improve how the body's operating. It sounds like it's a similar concept where if you have this more specific indication of what might be behind how your child's presenting, then again it gives you many more options of what you might be able to do. Now. It's not like, okay, that's the way it is and there's nothing I can do. There's always something you can do. Right?
- [09:55]
A
Yeah. And I think another context is when we talk about Judy's work that has these ranges of what percent of autism diagnoses could be caused by Mara coming from. Mara could be up to, as she mentioned, from 12% to 29% in her studies. To put some context in that, that's much, significantly more than any single genetic factor that's been identified to be related to autism. Think about Fragile X or think about some of these other genetic variants that are much less than 1%. Right. Or Fragile X might be 2 to 3%. We're talking about potentially the largest single contributor known to be contributor to an autism diagnosis. Right. And if you think about this being able to inform a parent even prior to conception, that allows family planning discussions to happen, that is really not available with respect to say, genetic testing.
- [10:52]
B
Sure. And I guess with, I know we're talking about autism, but my guess is the Mara, if that's prevalent, it might be manifesting in ways that aren't necessarily captured by an autism spectrum disorder diagnosis. Right. My guess is that there may be other ways the child's presenting that maybe don't have that autism label that this may actually be relevant for as well.
- [11:14]
C
One of the goals of my work is to understand how both Mara and other maternal factors might impact neurodevelopment. And in doing so, it is not just sort of a cut and dried Autism. Yes. Autism. No. Often it is a that spectrum also. There's a spectrum leading up to that diagnosis. Right. Of outcomes. And I think, you know, some work that we hopefully will have published soon suggests that there may be suggestions of auto antibody patterns that are related to developmental delay without autism. So I think we're starting to think about not just autism, yes, autism, no. But how we might be impacting various developmental outcomes or, you know, symptomatology. But I think the other really important part of this is this is maternal based, not fetal based, like, you know, much of the current testing that we do during pregnancy. And we don't ever have to test the child because this is. We can test the mom at any time. So we could test a mom right after birth and know, much like we do other testing in newborn blood, spot testing, we could test very early and understand what the risk might be, because we know that the earlier we have intervention, the early you know, the better the outcome is going to be. And I think our goal is not a cure, it's more a lessening the impact. Right. Of autism symptoms or autism. I keep wanting to use the word sequelae, but that is a very medical term. But, you know, autism symptomatology, the challenges that might be there, especially, I think another important note here is these are the more severe kids. And I think that is something that I'm very aware of when I am, you know, working in the community is these are the kids that are low language, will always need support, have severe repetitive behavior challenges, have intellectual disability, quite often depending on what pattern they have of these antibodies. So the hope is an earlier understanding of where that child might be heading. We can come up with ways to lessen that impact.
- [13:44]
B
Right. That is so important. And that leads me to, I think the next question, which is, now that this is available for people to be able to take this test and get more information, then it comes down to, okay, what do I do now? What can I do now? And for people who are listening to this podcast, likely you have a child who may be on the spectrum or have some other challenge currently. So from a parent's perspective, some may think, okay, why bother testing if I have this antibody? I already have a child, and how does that help me with this child? And even more important, though, for future planning for future children, I know that's where this really also works. So can you talk a little bit about how parents can actually use this information practically? What kind of actions does it lead to potentially?
- [14:33]
A
It's a great question. And I'll make some reference to what I have heard in the past talking with parents in my previous company, in which we had both counselors available to talk with both providers and with parents, one of the things that we heard quite often is, how did this happen? Okay, and what's the chance it's going to Happen again. And I think that's really where the strength of a parent accessing the test today is wanting to know etiology. How did this happen? Okay, it's not genetic. And if you think about that, that means, well, maybe that child doesn't have inherited the genetics that could be passed on. That could be really important from a family planning perspective. And then how could it happen? Could this happen again? We talk about recurrence risk, right? What's the risk of this happening? And we know that parents who have one child diagnosed with autism are at a higher risk rate of recurrence risk than the general population. But that's really a population based estimate. We can give a very specific estimate. The test is very accurate. It's about 97.5% predictive of risk of autism in a child. If the mom carries the antibodies, that could be very important from a family planning perspective. Or think about that younger sibling, let's say a family who has one child diagnosed with autism but has a younger sibling that potentially is pre symptomatic, and you would want to know what the chance is that child could go on and intervene much, much earlier than symptoms. I mean, isn't that something that we want to do generally as a society is intervene before symptoms exist and this gives that family that option. We know that there's many parent mediated interventions that are very productive in producing more favorable outcomes. And then a child, as Judy mentioned, if a family has a child with developmental symptomatology, is it autism? Is it something else? This would give them information that that symptomatology is due to or caused by the Morris subtype of autism and could help them triage care, could help them find the care faster than they might otherwise go. And again, knowing the long diagnostic odyssey that many parents are on, this could help shorten that journey to getting the best care possible at the earliest possible time.
- [17:05]
B
Right. So the specificity here will help with a parent finding care, whether that's what practitioner might be the one who is most skilled or has the relevant experience to perhaps help. And when you talk about interventions, where my mind goes only because it's what I do for a living, is I would say if a parent got this information, part of their action plan, and you correct me if I'm wrong, would be okay. Some of those interventions you can do relate to kind of reducing whatever toxic burden might be facing that family, which is where there's a lot of environmental stressors, where you can create a more healthful environment. The parent themselves can get into a more regulated State. Right. And not be, you know, so like all those factors, to me, those are the types of interventions that every family has the opportunity to do. But if you know that you have a more compromised child with more inherent potential challenges, those types of actions may become even more important. Does that strike the right chord with
- [18:11]
A
you and is no longer empiric. It's objective. Right. And you're right, most people could have. And I think that you hit another key point about the parents being able to be proactive in putting themselves in whatever better health state they feel like they need to be in, which you don't have the opportunity when it's a genetic form of autism. Right. You don't have the, you can't put yourself into a better genetic state, so to speak. But you can from an immune health. And I'll let Judy speak to that. You can from an immune health perspective put yourself in a perceived or desired better state prior to conceiving the next child, which this test will greatly inform kind of that process.
- [18:57]
C
I think there are a couple things that have come up. Just I get a lot of parent email asking questions about this because it, we've published papers, it's very public, you know, the research. And we recently got one from a family where they have three generations of autism in their family and wanting to be tested because they want to know, mind you, they're on the journey with the youngest one, you know, being only six and having a diagnosis. But they speaking more, you know, what Michael was asking, want to know. So there are sort of two, you know, you know, there are a couple of reasons that people, you know, would ask. And then the other is I have a child with autism. I would like to have another child. What, what is my risk? I would like to know my risk. And I think it's really also important to remind everyone that this is a rule in test, meaning if it's positive, highly, highly likely. But if it's negative, there are many routes to autism. So you're not ruling out that if you're negative you're good to go, but you've lessened your risk by understanding that you're negative by a certain percentage. So I think I always like to remind people of that because I think it's really important for the, on the consumer side to understand, you know, what this tells you and what it doesn't tell you to be. But I think we've got a lot of work to do in terms of understanding which interventions work best. But I think this is the other part where having the MARA test is made up of. There are multiple antibodies and they have. These patterns have different levels of impact. And we know this from our clinical studies and we know it from our animal models that we've got working. And so I think understanding which interventions work best with which pattern would be incredibly useful. And we know things like the early Start Denver model, all of these really early, especially from our infant SIB studies that have gone on that the high risk, sometimes the SIB which might have gone on to have autism because the early intervention was so effective, it kind of messed up the studies because they were like, we're doing these interventions and how do we know that this child would ever have been diagnosed? Because it was so effective during these really early interventional steps. So I think we have some work to do, you know, on the research side, certainly, to understand, you know, working with the clinicians at the Mind Institute to understand what interventions work best in each child, what these. The sort of I. The word more granular behaviors that might be associated with so this type of autism so that we can better target, you know, the. What would work and what doesn't work. So you don't waste time and money on things that are not going to work. Because I think I know, I know from being in this space for a really long time, that is a huge source of frustration for families because we as parents want the absolute best for our kids. So we throw everything we can at it. And I would like to lessen the burden of what they, you know, might need to do by better understanding, you know, the specific interventions that work well in the context of Mara.
- [22:40]
B
Yeah, I'll put myself in that category where I was one of those parents, right. Who did everything possible early on, wanting to see hope that things would be helpful and would improve outcomes. So I'm guessing that your research with your research hat on. Right. That's where you're going in terms of really understanding how having more data, more actual participants to be able to in a more scientific way, indicate what has more efficacy, what doesn't. And as we all know, with autism, it's so wildly unique to the individual that even those studies might give you an indication. But ultimately you won't know until you do perhaps take an intervention and see what the impact might be for your child. But those, that broad category I gave, my guess is a lot of those interventions are going to be where it's about just improving, you know, the ability for the. For the body, however it's set up to thrive. And that's where if you you know, remove toxins, remove stressors, you know, have the child consuming more nourishing food. Like it's, it's items like that that are so foundational. But again even more important for a child who may have these, this particular
- [23:56]
C
marker or when you're talking about food, that's a challenge, right. For families with an autistic child the stressor on the parent is my child only wants to eat five things. Right. And I think trying to remove the guilt that you're that pushing your kid to do something they don't want to do. But I think one of the things that we've learned from our animal studies is this particular and certain patterns have what we call a downstream effect of a little bit of a immune system development that is below normal. Which I think many people were surprised when we had, when we published that Everyone I think expected oh if you've got an autoimmune disorder during pregnancy you're going to have inflammation in the postnatal period. But actually we saw the opposite. They were below where they should be in terms of their immune function. These are the animals I have not done this in humans but which was both surprising but at the same time you can imagine the challenges that child might face health wise if they're in that state. And as you say getting them to the reducing any burden body burdens that might impact that their immune function. Being mindful they may have an exposure like influenza that's going to make them, it may hit them harder because they have less protection. What we also noticed in our animal model they eventually normalized more but it was so I think the best way to describe it is they were slow to develop their immune function. Um, we've seen this in clinically in kids with their antibody production themselves that low levels of ig, G, M and M early meaning they're going to be less protected. But around age 10 they started to kind of come up to where their neurotypical peers were. And that for me tells that's like okay, their immune system can function but it needs support early on because it's slow to develop. You know, it's a little bit behind. So I think I'm, I think of all of it when I'm working, you know, I mean I'm working not just in the auto antibodies but we're working you know across the entire, you know, mother and child spectrum. But you know there's just some things that we've learned. So I think to what you were suggesting having that really is healthy an environment as you can have is going to help.
- [26:32]
A
And Lynn, if I could just come back to one point, you made a really critical point about personalization, more personalization of treatment for the child. And I think that's something as you Judy's certainly working on, but that's something that we're working on as a company also. We think it's critically important that with the ability. If you think about other areas of medicine, people talk about personalized medicine. Well, you get to personalized medicine by identifying the cause of a particular form of a disorder. Right. And we think really we're on the leading edge in personalizing treatments for autism for kids, even behavioral treatments, by knowing that this subtype is the likely cause for those symptoms and then identifying working with clinical research centers, which we are including one of the largest autism research centers in the country, treatment centers in the country, to identify which behavioral approaches could work best in children who have a form of the MARA subtype of autism and avoid those treatments. As Judy mentioned, one of the frustrating to avoid the treatments that don't work and to get to really that personalized therapy approach based on the understanding that this particular autism is a unique subtype and has unique properties and can have unique outcomes. If you understand that again, going back to your earlier detection, the more options you would have.
- [28:10]
B
Right. No, understood. And that's what's exciting now, right? That level of personalization, given the tools we now have available to take lots of data and to be able to understand the interrelationships, we've never been in a better position to be able to personalize. It's also quite overwhelming. But otherwise there's a lot of hope for the ability to have effective personalization like that. And I just have to go back to the whole diet, the food thing, because I know that is such a source of stress for so many families with picky eaters with kids who are very self limiting. And again, no judgment on anyone. But there's no question I didn't want to take the diet thing seriously at all. I went kicking and screaming, especially with my son having true allergies to gluten and dairy. That forced my hand because otherwise I'm an Italian living in Carroll Gardens, Brooklyn, where the whole diet is gluten and dairy. So I think I appreciate that everyone's in a unique position and it can be very challenging with a child. But if you have this information saying, hey, you know something nourishing food, food for your child is actually even more important, then it can help you go from wherever you are to then Having the courage to take some actions in the right direction. It doesn't mean you go from a very limited diet to gluten free, dairy free, GAPS diet overnight. It just might mean that you start consuming more organic food as opposed to food with pesticides on it. Right. So you can take actions in the right direction and that doesn't have to create more overwhelm. But I appreciate food can be such a challenging situation for many families.
- [29:52]
C
As we think about the full picture. I think also about comorbidities and autism is a big challenge. Sleep, GI issues, all of those things. If the kids can feel, feel better, they're going to do better with any behavior intervention you have. Right. So I think that is also another important piece is understanding, you know, where your child is medically, you know, physically. All of it is very helpful in as you're on that journey to help them behaviorally.
- [30:31]
B
Yep, makes sense. And so with this whole process and what you've created with Marabaio, can you just talk a little bit more about if a parent raises their hand, they want to know, which again I know can be hard for some. I didn't want to know a lot of things. But if they raise their hand, they want to know, they dive in. What does the process look like for them in terms of acquiring this test? And just can you describe what it is from a parent's perspective?
- [30:59]
A
Sure. We really try to be very family forward company and this is something that I think we all believe in. I think we're in this space for a collective purpose to help. And so we have provided many convenient mechanisms for a parent to access the test. Currently the parent would, let's say a mom or a family that has one child diagnosed with autism would be a candidate for the test or whether that's with a current sibling or a future pregnancy and also for a parent with a child with developmental symptoms. So those families could easily come to our website that we have and enter their information because we know that is very challenging for parents to get their children, maybe with autism or other developmental conditions to a doctor, much less getting themselves to a doctor and having somebody watch their child. So we really want to bring, instead of asking them to go to a doctor, we want to bring the doctor to them. And so they can go onto the website, apply or just enter their information. And then through a telehealth, very convenient telehealth channel would be able to order the test because it does have to go through a provider. It could go through the child's pediatrician, it could go through the mom's provider or it could go through a provider through our telehealth channel. And then as Judy mentioned, we don't need a sample from the child, which was very traumatic in, let's say from genetic testing, needing a blood sample or something from a child. We avoid that altogether. We just need a blood sample from the mom and we can go to any blood draw site, any place where you go get your normal blood taken. We arrange all of that and then we analyze the results and then we provide the results back through that ordering provider to the parent so that they would know and then we provide some ability to help counsel if that's a possibility. They can find help also through their own provider. In terms of next steps, we really want to be that family forward convenience option because we just know the challenges involved.
- [33:17]
B
Great. I appreciate you explaining what that process looks like and coming from someone who's. Along with my wife Cass, we've invested so much in testing and much of the testing we did and never did anything with which is just basically burning money when you do that. So the key is if you're going to test whether it's for your child or yourself to choose wisely and it seems like what you've created is something that truly can be very important to understand the earlier the better. And so again, I think I really appreciate all the years, decades of research that went into this as we learn more about what's behind how our kids may be expressing. So I'll include in the show notes the links where people can reach out and find out more. I guess I'd ask both of you if there's knowing the audience is already parents who are all in doing what they can, maybe relatively newly diagnosed, but probably been on this journey a little bit. Is there any bottom line insight that you wish parents knew earlier that you'd like to share? And I guess I'll start with. Let's start with you, Michael.
- [34:24]
A
That options exist, right? And that once you have more options, your ability to care both for yourself because. Because I think that's really important from this Mara subtype is to help the families, the parents care with respect to potentially putting yourself in a better health state, to caring for the child earlier and this could be in that. And this is where I think that when you talk about taking a lot of tests and I really appreciate that and I know that many families are confronted with many tests. We believe this provides unique information and we want that unique information to be providing new options or unique options for the families to Find the care for their child sooner and also to care for themselves earlier, prior to, let's say, a second pregnancy. Because family planning is important for everybody. And again, we want to be very family. We're very family aware organization. And that's what's important to us is helping the parents care best for their kids and for themselves.
- [35:30]
B
Great. No, I appreciate that. I think the key is heightened awareness. It's one thing to say for parents to become better aware, but in this case this is now an option to become even more, in a more heightened way to be really aware of what's going on. Again, to be able to inform, not for shame, guilt, not for anything of that nature. Not to say, hey, here's the cause. It's like, all right, now I have this information. This, this can inform actions I can take now. So no, I appreciate that insight. Dr. Judy, you could choose whether it's with your research hat or with your commercial hat. What would you think? Again, you've been at this for a long, long time. What is it something that parents just would really benefit from knowing earlier on that you think is worth mentioning?
- [36:14]
C
I think so. Michael took care of my Mara bio hat because the, frankly, once, once we got this out of my lab, I put in the, in the team who's more capable of handling this than myself and stayed in the research realm. I think there are a couple things. One is, I know it's frustrating for parents how slow research happens because you want answers now. And that is, you know, we are very aware of that. But at the same time, whatever answers we provide, we want to be sure. And that's why this took so long. Because I came into autism at a time when there were a lot of theories going around back in 2000. And I think that did some harm to the research community and probably to the parent community in sort of putting people down a track that might not have been in their best interest. But I think we work hard to do it as quickly as we can. But we're always thinking, are we right? We question ourselves constantly. Because that is what you do in research. You don't say, okay, I got it. You're constantly striving to provide the best possible information. I wish we could work faster, but sometimes it takes time. And I think I'm, I continue on the journey of what these antibodies are doing because there may be down the road other things that we can do to modify the outcome. And that's what we have our animal models for, because we can test those things. We're work, we're starting to move into brain organoids to do the same thing. And I think, you know, we, that is just, that's where I live. And I mean, I, I could retire tomorrow, but I still, I can't because I have more questions to answer. You know, this, this is, it is something that I've dedicated, you know, a lot of, of my time to. But I think also important is I think, you know, we never want to lose hope.
- [38:20]
B
No question. No question. I think that's a lovely sentiment to, to end on. And again, I know research inherently moves slow. It's just the way it is. And I think you want it to. Right? Because there's people who do research and make proclama that are premature. So to do it right is important. And again, I think what's emerged with Marabayo is the product of decades. Right. Decades of thought and research. And so I so appreciate what each of you have brought to the table and making this available to families. So I'm excited to share it. And again, I really appreciate you both lending your voice for this podcast. So thank you so much.
- [39:00]
C
Thank you so much for having us.
- [39:02]
A
Yeah. And thanks for all you're doing for the families. I think that's really important.
- [39:06]
B
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